Barriers to malaria interventions in Ghana

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Malaria in pregnancy can have a devastating effect on pregnant women and their unborn children. Consequently, various intervention measures have been put in place to prevent and manage malaria among pregnant women in endemic countries such as Ghana. However, malaria continues to afflict some pregnant women.

The problem

Although malaria is preventable, it remains a leading cause of illness and death in sub-Saharan Africa (SSA), which suffered 92% of malaria cases and 93% of malaria deaths worldwide in 2017. The most at-risk populations include children and pregnant women. Malaria in pregnancy (MiP) is associated with negative outcomes such as illness requiring hospitalization, anemia, aborted pregnancy, low birth weight and still births, especially in first time pregnancies.

In SSA, an estimated 25 million pregnant women are at risk of infection by Plasmodium falciparum annually. The World Health Organization (WHO) recommends that malaria in pregnancy interventions be included as a component of maternal health care. Ghana adopted the following interventions in 2003: regular use of long-lasting insecticide-treated bed nets; directly observed administration of intermittent preventive treatment (DOT) with sulphadoxine-pyrimethamine — a full therapeutic course of antimalarial medicine given to pregnant women at routine antenatal care visits regardless of whether the recipient is infected with malaria.

A study in eight health facilities and eight communities with high incidence of malaria in pregnancy in two administrative regions of Ghana suggested that socio-cultural, household, individual and health system factors influenced knowledge, attitudes and utilization of malaria interventions in pregnancy.

Negative pregnancy outcomes such as miscarriage and still birth from malaria and other biomedical causes were sometimes interpreted as spiritual attacks from enemies. So pregnant women were encouraged to seek physical and spiritual protection, which resulted in women visiting prayer centres, herbalists and self-medicating using herbs. This practice contributed to delay in seeking maternal and MiP care in health facilities and compliance with treatment. However, the belief that pregnant women should not be abused and should not be starved contributed positively to the protection of pregnant women from violence and encouraged them to develop regular eating habits.

Healthcare managers reported that sometimes the National Malaria Control Programme failed to supply them with antimalarial drugs and supplies and the National Health Insurance Scheme delayed in reimbursing them for services provided.

Multiple factors such as the nature of the healthcare system, socio-cultural and individual influences impact the uptake of malaria in pregnancy interventions.

The lessons

To ensure seamless delivery of services in order to achieve the goal of controlling malaria during pregnancy in Ghana, authorities must provide a regular supply of antimalarial drugs and medical supplies and products, as well as prompt reimbursement of funds to public, faith-based and private health facilities.

The same factors influence the uptake of some drugs. Consequently, interventions must focus on three levels: regular and sufficient supply of essential drugs in health facilities; provision of appropriate and adequate information, education and communication to antenatal clients to motivate them to complete required dosages, and community outreach programs to encourage early and regular antenatal care visits.

Intensive and regular education must be provided by health providers to pregnant women to improve their knowledge of the effects of malaria in pregnancy and MiP interventions to facilitate prompt utilization of preventive and treatment services.

Distributors of long-lasting insecticide bed nets in health facilities and communities must also provide comprehensive, culturally-appropriate information.

Facility managers must ensure that antenatal care managers have access to transport to reliably distribute drugs to health facilities in order to ensure that all pregnant women who seek antenatal care for the first time receive them for onward use.

Positive socio-cultural beliefs should be further studied and encouraged among communities to promote healthy habits among pregnant women, while negative practices should be discouraged through extensive community education. – This article was first published as part of  a series of case studies and impact from researchers funded through the Alliance for Excellence in Science in Africa (AESA), a platform of the African Academy of Sciences and African Union Development Agency (AUDA-NEPAD).